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          <h1 class="post-title" itemprop="name headline">《Newman and Carranza's Clinical Periodontology》读书笔记08</h1>
        

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        <p>第50章<br><strong>可进入性(Accessibility):患者和医生的体位</strong><br>患者和医生的体位需要提供进入操作区域的最大程度的便利。<br>术者体位：脚平放在地板上，大腿平行于地板。术者在保持后背和头直立的情况下应该能看到术野。<br>患者体位：仰卧位，闭嘴时口腔接近术者肘部。对于上颌操作，患者要稍抬颏部，提供更好的视野。对于下颌操作，需要轻微抬起牙椅，要求患者颏部向下，直到下颌与地面平行。对于下颌前牙舌侧操作，这样尤其便利。<br><strong>能见度，照明和反射</strong><br>任何时候，能够直接照明并直视是最理想的。如果不可能达到，用口镜达到间接观察，以及用口镜反光使用间接照明。间接观察和间接照明通常同时使用。使用间接照明或间接观察时，要注意避免错误的角度。如果嘴唇和皮肤是干燥的，涂凡士林有助于预防粘膜干裂和出血。<br><strong>器械的条件和锋利度(Sharpness)</strong><br>在进行任何操作前，必须检查器械以确定其是否清洁，无菌，并处于良好的条件下。器械的工作端必须锋利。锐利的器械有助于提高触觉感受，使术者的操作更加有效和精确。钝的器械会导致刮治不彻底，以及不必要的损伤。<br><strong>保持清晰的术野</strong><br>术野会被唾液，血液，或者牙石碎片等影响。<br><strong>器械的稳定性</strong><br>器械和手的稳定性是控制操作的首要要求。这对有效操作和避免患者和医生的损伤都是必要的。影响器械稳定性的两个因素是器械的握持和手指支点。<br>①器械握持(Instrument Grasp)<br>最有效和稳定的握持器械方法为改良执笔式。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0067-lcyzbxbj08/01.jpg"><br>拇指，示指和中指像握一支铅笔一样握持器械，但中指放置使得靠近指甲的那一侧像是靠在器械柄上休息。示指第二个关节弯曲，靠在与中指同侧的器械上。拇指指腹放在中指与示指之间，在柄的另一侧。这形成了一个三角力，或者三角效应，促进对器械的控制。原因是它对抗了在刮治时器械在手指尖不受控制的旋转的趋势。它允许医生将器械旋转一个精确的角度。 它同样增强了术者的触觉感觉，原因是中指放在器械柄上时触觉很敏感。<br>掌拇握持法(palm and thumb grasp)在研磨器械和操作三用枪（air and water syringes)时很有用，但在进行牙周治疗时不建议使用。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0067-lcyzbxbj08/02.jpg"><br>②手指支点<br>为手和器械提供一个稳固的支点。<br>良好的手指支点预防牙龈和周围组织的损伤和撕裂。无名指是多数牙医喜欢使用的手指支点。尽管有可能使用中指作为支点，并不建议这样，因为这样在施力的时候会限制运动弧度，并会严重影响中指的控制和触觉功能。要达到最大程度的控制，中指需要在器械和无名指之间。这种构建起来(built-up)的支点是刮除牙石时腕关节前臂运动的一个组成部分。任何可能的时候，这两根手指应该在一起工作，像一个支点单元。在刮治用力的时候中指和无名指分开用力会导致力量和控制的丧失。<br>手指支点可以分为口内支点和口外支点。口内支点用靠近工作区的牙齿作为支点，当口内临近工作区支点无法提供良好的角度和运动路径时，可以用各种各样的口内和口外支点。<br>a.常规支点(conventional):手指支点在工作区域的邻牙表面。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0067-lcyzbxbj08/03.jpg"><br>b.跨弓支点(cross-arch):手指支点在同一牙弓的对侧。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0067-lcyzbxbj08/04.jpg"><br>c.对侧牙弓支点(opposite arch):在对颌建立的支点。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0067-lcyzbxbj08/05.jpg"><br>d.手指支点(finger on finger):建立在非操作手示指或拇指上的支点。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0067-lcyzbxbj08/06.jpg"><br>对于上颌后牙区域的牙齿，口外支点很有必要。在口外支点中，尽量用手指前部或后部做支点，以提供最大程度的稳定性。两种最常见的口外支点：<br>a.手掌向上(palm up):通过用中指或无名指的背部在皮肤上做支点，在下颌的右侧。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0067-lcyzbxbj08/07.jpg"><br>b.手掌向下(palm down):用中指或无名指的前部在下颌的左侧皮肤上。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0067-lcyzbxbj08/08.jpg"><br>无论口内还是口外支点都可以用非操作手的示指或拇指握持器械的柄进行加强。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0067-lcyzbxbj08/09.jpg"><br><strong>器械运动(instrument activation)</strong><br>适配(Adaptation)：表示牙周器械的工作末端贴近牙齿表面的方式。适配的目的是使器械末端进入牙齿表面轮廓更加舒适。精确的适配是所有器械都需要的，以避免对软组织，牙根表面的损伤，以及确保器械的最大使用效率。<br>探针的准确适配很简单。探针的尖端和侧面要贴着牙齿表面垂直插入间隙。刃状器械和尖端器械比较难以适配。器械的尖端是锐利的，可能割伤组织，因此龈下区域的适配变得特别重要。工作端的尖1/3，在插入时必须保持与牙面持续接触。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0067-lcyzbxbj08/10.jpg"><br>精确的匹配通过小心的翻转手柄来达到。在凹凸的区域如线角，不可能使器械适配牙面超过1-2mm。即使在宽的，平坦的表面，除了尖端的1-2mm其它区域也无法适配。因为牙齿表面看起来是平的，但实际上是有轻微的弧度。<br>如果只有器械中部1/3在凹陷表面与牙体匹配，器械的尖端可能会损伤软组织。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0067-lcyzbxbj08/11.jpg"><br>如果器械仅尖端与牙体接触，软组织会被工作末端的背部扩张或压缩，带来损伤或不适。不适合的刮治器械以这种方式匹配尤其有害，因为会损伤根面。<br>(总结：就是要使器械工作端尽可能贴合牙面，尤其是尖端1/3。)<br>角度(Angulation):代表器械刃的表面与牙齿表面间的角度。也被叫做牙-刃关系(tooth-blade relationship)。<br>对于插入龈下的刮治器，角度应该尽可能接近0度。当工作端与牙面平齐插入时，更容易进入。在刮治和根面平整时，可以选择45°-90°角。确切的角度取决于牙石的量和性质，病情的进程，以及组织的条件。要减小角度，将器械的短柄倾斜靠近牙面。要增大角度，倾斜短柄离开牙面。刮比较硬的牙石的时候，角度要接近90°，这样切端会“咬”进牙石。如果角度小于45°，切端不能很好的咬入牙石，而会滑过牙石。平滑或“磨光”（burnishing)它。如果角度超过90°，刃的侧面，而不是切割刃，与牙齿相对，牙石不能刮除。在牙石去除后，接近90°的角度要保持，用小一些的力进行根面平整。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0067-lcyzbxbj08/12.jpg"><br>(总结：以接近0°进入，到牙石底部以后，用45°-90°的角度刮除牙石，小于45°，没有刮治作用，大于90°，工作刃没有与牙石接触，同样无作用。）<br>侧向的力应当稳定，中度或轻度用力。当去除牙石时，侧向力开始时用稳定的，轻柔的力，渐渐减轻直到用轻柔的力完成根面平整。当用不适当的力去除较多的牙石，粗糙根面也许会被刮成薄的，光滑片状的牙石，从而难以被探查和刮除。这常发生于正在沉积的区域和釉牙骨质界附近。<br>在刮治时，不加区别的，不留意的，不受控制的使用重的力应该避免。<br>施力(Strokes):刮治时使用三种基本类型的力：探查的力(exploratory stroke)，刮治的力(scaling stroke)，以及根面平整的力(root-planing stroke。这些力在使用时都要采用在垂直方向，倾斜方向或水平反向上拉或推的力。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0067-lcyzbxbj08/13.jpg"><br>垂直或倾斜的力最常见，水平的力选择性的用于线角或深袋。由四个因素决定：①牙龈位置和颜色；②袋深度和袋的形状；③牙齿轮廓；④牙石或粗糙面的数量和性质。<br>探查力是一个轻的“感觉”力，用来探查以评估牙周袋的大小，探查牙齿表面的牙石和粗糙。<br>刮治力是一个短的，有力的力，用刃状器械去除龈上和龈下牙石。<br>根面平整力，是一个中度到轻度的拉力，用来最后光滑和平整牙根表面。刮治器是最常使用而且最有效的器械。<br>(总结：这部分主要是体位，器械的握持，支点的选择，进入角度，用力等基本知识。)</p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的知乎文章地址： <a target="_blank" rel="noopener" href="https://www.zhihu.com/people/zhao-you-min/posts">https://www.zhihu.com/people/zhao-you-min/posts</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/other/wx.jpg"></p>

      
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